Taylor James A, Winter Laura, Geyer Leah J, Hawkins Douglas S
Department of Pediatrics, University of Washington and Children's Hospital and Regional Medical Center, Seattle, Washington 98195, USA.
Cancer. 2006 Sep 15;107(6):1400-6. doi: 10.1002/cncr.22131.
Although medication errors are 1 of the most common types of medical errors, their frequency in pediatric patients receiving oral outpatient chemotherapeutic agents is unknown. The prescribing, dispensing, and parental administration of these medications to children receiving treatment for acute lymphoblastic leukemia (ALL) were systematically reviewed to determine the rate and types of medication errors occurring in these patients.
During a 2-month study period, parents of children with ALL were contacted and asked to participate in the study before a regularly scheduled clinic appointment. At the visit, the parent demonstrated how each medication was administered. A pediatric oncologist reviewed the medical record to determine the correct treatment regimen for study patients. After comparing the correct treatment regimen with what was administered, a classification of "no medication error," "medication error," or "cannot determine" due to insufficient information was made for each indicated drug. Identified medication errors were subclassified as prescribing, dispensing, or administration errors.
Data on 172 chemotherapeutic medications for 69 patients were analyzed. One or more errors occurred with 17 of the 172 (9.9%) medications; a classification of "cannot determine" was made for 12 (7.0%) medications. Among the 17 medication errors there were 12 (7.0%) administration errors and 5 (2.9%) prescribing errors. There were no pharmacy dispensing errors. All errors were due to incorrect dosing or failure to administer an indicated medication. At least 1 medication error occurred in 13 of the 69 (18.8%) study patients.
Prescribing and administration medication errors occurred with nearly 10% of chemotherapeutic drugs administered to outpatient children with ALL. Systematic changes, including computerized physician order entry and simplification of treatment protocols, should be considered.
尽管用药错误是最常见的医疗错误类型之一，但接受口服门诊化疗药物的儿科患者中用药错误的发生率尚不清楚。对这些药物在接受急性淋巴细胞白血病（ALL）治疗的儿童中的处方、配药和家长给药情况进行了系统回顾，以确定这些患者中发生的用药错误的发生率和类型。
在为期2个月的研究期间，在预定的门诊预约前联系了ALL患儿的家长并邀请他们参与研究。在就诊时，家长演示了每种药物的给药方式。一名儿科肿瘤学家查阅病历以确定研究患者的正确治疗方案。将正确的治疗方案与实际给药情况进行比较后，对每种指定药物进行“无用药错误”、“用药错误”或因信息不足而“无法确定”的分类。识别出的用药错误被进一步细分为处方错误、配药错误或给药错误。
分析了69名患者的172种化疗药物的数据。172种药物中有17种（9.9%）出现了一个或多个错误；12种（7.0%）药物被分类为“无法确定”。在17例用药错误中，有12例（7.0%）为给药错误，5例（2.9%）为处方错误。没有药房配药错误。所有错误均因剂量错误或未给予指定药物。69名研究患者中有13名（18.8%）至少出现了一次用药错误。
在接受ALL门诊治疗的儿童中，近10%的化疗药物出现了处方和给药用药错误。应考虑进行系统性改变，包括计算机化医嘱录入和简化治疗方案。
